The Nutrition Care Process: Driving Effective Intervention and Outcomes

Nutrition Care Process Process for identifying, planning for, and

meeting nutritional needs Malnutrition increases:

– morbidity– length of hospital stay = more care– mortality– higher costs ($$$$$$$)

Relationship Between

Patient/Client/Group & Dietetics

Professional

-

Nutrition Diagnosis Identify and label problem Determine cause/contributing risk

factors Cluster signs and symptoms/

defining characteristics

Nutrition Assessment Obtain/collect timely and

appropriate data Analyze/interpret with

evidence - based standards

Identify risk factors Use appropriate tools

and methods Involve

interdisciplinary collaboration

Screening & Referral System

Outcomes Management Sys tem

Monitor the success of the Nutrition Care Process implementation

Evaluate the impact with aggregate data Identify and analyze causes of less than

optimal performance and outcomes Refine the use of the Nutrition Care

Process

ADA NUTRITION CARE PROCESS AND MODEL

Document

Nutrition Monitoring and Evaluation Monitor progress Measure outcome indicators Evaluate outcomes Document

Nutrition Intervention Plan nutrition intervention

Formulate goals and determine a plan of action

Implement the nutrition intervention Care is delivered and actions

are carried out Document

Document

Central Core of Nutrition Care Model

The relationship

between the client &

the dietetics

professional(s)– collaborative

– client-focused

– individualized

Outer Rings of Nutrition Care Model

Strengths brought to process by dietetics professional– dietetics knowledge

– skills of critical thinking, collaboration, communication

– evidence-based practice

Factors of external environment– health care system, practice setting

– social support, economics, education level

ADA’s Nutrition Care Process Steps

Nutrition Assessment Nutrition Diagnosis Nutrition Intervention Nutrition Monitoring and Evaluation

For more information, access the ADA member page in the Quality Management section. http://www.eatright.org/Member/83_12962.cfm

Nutrition Assessment Components Gather data, considering

– Dietary intake

– Nutrition related consequences of health and disease condition

– Psycho-social, functional, and behavioral factors

– Knowledge, readiness, and potential for change

Compare to relevant standards Identify possible problem areas

Example of Nutrition Assessment Content

Nutritionassessmentwhat data are most

effective for identifying

clients’ nutrition related

problem of interest

Type of assessmentContent component Nutritional adequacy Fat and cholesterol intake Trans fatty acid intake Health status

Lipid profile BMI Waist circumference

What are the reliablestandards (ideal goals)?

• how well, how much, how long

What type of

assessment data?

How do we get from Assessment to Intervention?

Nutrition Diagnosis

A crucial element of providing quality nutrition care

Nutrition Diagnosis

Purpose Identify and label the nutrition problem Nutrition diagnosis

NOT medical diagnosis EXPLICIT statement of nutrition diagnosis

Note: Documentation is an on-going process that supports all the steps in the Nutrition Care Process

Nutrition Intervention

Purpose Plan and implement purposeful actions to address

the identified nutrition problem– bring about change– set goals and expected outcomes– client-driven– based on scientific principles and best available

evidence

Note: Documentation is an on-going process that supports all the steps in the Nutrition Care Process

Nutrition Monitoring & Evaluation

Purpose Determine the progress that is being made toward the

client’s goals or desired outcomes Monitoring: review and measurement of statusat scheduled times Evaluation: systematic comparison with previous status,

intervention goals, reference standard

Note: Documentation is an on-going process thatsupports all the steps in the Nutrition Care Process

Nutrition Screening Purpose: To quickly identify individuals

who are malnourished or at nutritional risk and to determine if a more detailed assessment is warranted

Usually completed by DTR, nurse, physician, or other qualified health care professional

At-risk patients referred to RD

Characteristics of Nutrition Screening

Simple and easy to complete Routine data Cost effective Effective in identifying nutritional

problems Reliable and valid

Nutrition QuestionnaireNutrition Questionnaire

Nutrition Screening Tools Acute-care hospital or residential setting Perinatal service Pediatric practice Malnutrition Universal Screening Tool

(MUST) Nutrition Screening Initiative (NSI)

Food and Nutrient Intake Risk Factors Calorie or protein, vitamin and mineral intake

greater or less than required Swallowing difficulties Gastrointestinal disturbances, bowel irregularity Impaired cognitive function or depression Unusual food habits (pica) Misuse of supplements Restricted diet Inability or unwillingness to consume food Increase or decrease in activities of daily living

Hammond KA. Assessment: Dietary and Clinical Data. In Krause, 12 th edition, p. 386

Psychological/Social Risk Factors Language barriers Low literacy Cultural or religious factors Emotional disturbances associated with feeding difficulties

(e.g., depression) Limited resources for food preparation or obtaining food

or supplies Alcohol or drug addiction Limited or low income Lack of ability to communicate needs Limited use or understanding of community resources

Hammond KA. Assessment: Dietary and Clinical Data. In Krause, 12 th edition, p. 386

Physical Risk Factors

Extreme age (adults >80 years, premature infants, very young children)

Pregnancy: adolescent, closely spaced, or three or more pregnancies

Alterations in anthropometric measurements, marked overweight/ underweight for age, height, both; depressed somatic fat and muscle stores

NOTE: recent unintentional weight loss is more predictive of morbidity/mortality than wt/ht status

Hammond KA. Assessment: Dietary and Clinical Data. In Krause, 12th edition, p. 386

Physical Risk Factors (cont)

Chronic renal/cardiac disease, diabetes, pressure ulcers, cancer, AIDS, GI complications, hypermetabolic stress, immobility, osteoporosis, neurological impairments, visual impairments

Hammond KA. Assessment: Dietary and Clinical Data. In Krause, 12th edition, p. 386

Abnormal Laboratory Values

Visceral proteins (albumin, prealbumin, transferrin)

Lipid profile (cholesterol, HDL, LDL, triglycerides)

Hemoglobin, hematocrit, other blood tests BUN, creatinine, electrolytes Fasting and PP blood glucose levels, A1C

Hammond KA. Assessment: Dietary and Clinical Data. In Krause, 12th edition, p. 386

Medications Chronic use Multiple and concurrent use

(polypharmacy) Drug-nutrient interactions

Joint Commission Standards Drive Nutrition Screening in Health Care Organizations

Nutrition Care Process: Screening The Joint Commission (TJC) requires

that nutritional risk be identified within 24 hrs in all hospitalized pts

TJC also requires nutrition screening in accredited ambulatory facilities

Standards of Care protocols determines process; evidence-based guidelines

Use simple techniques, available info May be done by other than RD Usually simple form with targeted info

Standard PC.2.20:The hospital defines in writing the data and information gathered during assessment and reassessment

Elements of Performance The information...to be gathered during the initial

assessment includes the following, as relevant...:

– Each patient's nutrition and hydration status, as appropriate

The hospital has defined criteria for when nutritional plans must be developed

Standard PC.2.120: The hospital defines in writing the time frame(s) for conducting the initial assessment(s).

Elements of Performance A nutritional screening, when warranted by the

patient's needs or condition, is completed within no more than 24 hours of inpatient admission – CAMH online version, 2006

Standards Relating to Nutrition Assessment

Standard PC.2.130 Initial assessments are performed as defined

by the hospital.

Standard PC.2.150 Patients are reassessed5 as needed.

CAMH online version, 2006

Screening for Malnutrition in Acute Care Settings

“The consensus of the committee is that while screening for nutrition risk in the acute care setting is crucial, the JCAHO requirement that nutrition screening be completed within 24 hours of admission is not evidence-based and may produce inaccurate and misleading results.”

• Institute of Medicine, 1999

Commonly Used Criteria for Nutrition Risk Screening-Acute Care Diagnosis Weight Weight change Need for diet

modification or education

Laboratory values (s. albumin, cholesterol, hemoglobin, TLC

Problems with chewing or swallowing

Diarrhea Constipation Food dislikes or

intolerance

Institute of Medicine, 1999

Nutrition Screening and Assessment Tool

Courtesy Carolinas Medical Center, Charlotte, N.C.

Prevalence of Nutrition Risk in Acute Care The prevalence of nutrition risk will vary

depending on the population screened and the criteria used for screening

In published studies, prevalence of malnutrition in hospitalized patients has ranged from 12% to more than 50%

There is little published data regarding nutrition screening for other purposes

Malnutrition in Hospitalized PtsPopulation Criteria Prevalence

Warnold etal, 1984

Noncancer pts inSweden (n=215)

Wt loss, Wt/Ht,s. alb, AMC

12%

Messner etal, 1991

VA patients(n=500)

s. alb, TLC, wtloss

55%

Robinson etal, 1987

Medicine pts(n=100)

Wt loss, lab data,anthropometrics

40%

Chima et al,1997

Medicine pts(n=173)

s. alb, wt loss,wt/ht

32%

Thomas, etal, 2002

Subacute pts(837)

Lab data,anthropometrics,MNA score

29%

CNM Nutrition Screening SurveyChima and Seher, 2007

Blast email sent to 1668 members of the Clinical Nutrition Management dietetic practice group in May, 2007

522 usable surveys were returned, for a response rate of 31%

Does Your Health Care Organization Screen Patients for Nutrition Risk?

99

63

0

10

20

30

40

50

60

70

80

90

100

Inpatient (n=522) Ambulatory (n=345)

% of Respondents

(with accredited ambulatory clinics)

Screening in Acute Care

Who Has Primary Responsibility for Nutrition Screening (Inpatient)?

6.5

74

83

68.5

1710 8

50

10

20

30

40

50

60

70

80

90

Nursing Nutrition Other

1987 CNM survey(n=46)2003 CNM survey(n=110)2007 CNM (n=514)

*In the 1987 survey, only 60% of 77 respondents reported admission nutrition screening

% of Respondents

Criteria Used by Nursing in Nutrition Screening (n=442)Criterion N %

History of weight loss 418 95%

Poor intake pta 360 81%

Patient is on nutrition support 349 79%

Chewing/swallowing issues 333 75%

Skin breakdown 319 72%

Pregnant/lactating mother off OB 197 45%

Diagnosis 167 38%

Need for education 160 36%

Geriatric surgical patient 148 33%

Criteria Used by Nursing in Nutrition Screening (n=442)Criterion N %

Specific diet orders 105 24%

Food allergy 103 23%

NPO/Clear liquid in-house 84 19%

Weight for height criterion 75 17%

Age (premature or geriatric) 71 16%

Visceral proteins (albumin, PAB) 51 12%

Infant on concentrated formula 43 10%

Body mass index 38 9%

Other 111 25%

How Were Nursing Screening Criteria Chosen?

0

10

20

30

40

50

60

70

ReadilyAvailable

Easy toUse

No ClinicalExpertise

EvidenceBased

Testedand

Validated

Seem toWork Well

TJCRequires

It

% ofrespondents(n=442)

Where Are Nursing Screening Results Documented in the MR?

0

10

20

30

40

50

60

70

Nursing AdmittingAssessment

Other Specific Form ComputerizedRecord

InterdisciplinaryForm

% ofRespondents(n=442)

How Are + Nursing Screens Communicated to Nutrition Staff?

0

10

20

30

40

50

60

70

80

90

Fax Phone Computer Other N/A

% ofRespondents,n=438

If Nursing Screens, Do Nutrition Staff Do a Secondary Screen?

57

43

0

10

20

30

40

50

60

Yes No

% of respondents(n=441)

Why Do Nutrition Staff (NS) Do Secondary Screening?

% n

NS screens identify patients missed by NU screens

62% 158

Criteria used by NS may not identify pts at nutrition risk

46% 117

NU screens may not be completed 50% 129

NU screens may be unreliable 34% 86

NS staff may not be notified of + NU screens

46% 118

Other 24% 61

Characteristics of Secondary Nutrition Screening

% n

Nutrition staff (NS) screens use different data than NU

61% 156

Nutrition staff (NS) collect the same data as NU

12% 30

NS utilize criteria that require nutrition expertise

55% 139

Other 6% 14

Who Is Responsible for Secondary Nutrition Screening?

0

10

20

30

40

50

60

70

Dietitians DTR BS Nutr Clerk Other

% ofRespondents(n=256)

Criteria Used by Nutrition Staff in Secondary Screening (n=258)Criterion N %

Diagnosis 223 86%

NPO/Clear in-house 192 74%

Patient on nutrition support 190 74%

Specific diet orders 161 62%

Visceral proteins (albumin, PAB) 158 61%

Chewing/swallowing issues 139 54%

Skin breakdown 137 53%

History of weight loss 136 53%

Weight for height criterion 119 46%

Criteria Used by Nutrition Staff in Secondary Screening (n=258)

Criterion N %

Poor intake prior to admission 110 43%

Need for education 95 37%

BMI 93 36

Food allergy 89 35%

Geriatric surgical patient 83 33

Pregnant/lactating outside OB 79 31%

Age (premature or geriatric) 78 30%

Infant on concentrated formula 44 17%

Other 40 15%

Where Is Secondary Screening Documented in the Medical Record?

15

28 28

23

5

0

5

10

15

20

25

30

ChartForm

Computer ProgressNote

Not Doc InterdForm

% ofRespondentsn=260

Criteria Used by Nursing/Nutrition to Identify Patients at Nutrition Risk (Inpatient)

95

53

81

43

75

54

7974 72

5345

31

0

10

20

30

40

50

60

70

80

90

100

Wt Loss Poor IntakePTA

Chewing/Swallowing

EN/PN Skin Brkdwn Preg/Lactating

% of RespNursing Scrnn= 442

% RespNutritionScreenn=252

Criteria Used By Nursing/Nutrition to Identify Patients at Nutrition Risk (Inpatient)

24

62

38

86

33 33 36 37

0

10

20

30

40

50

60

70

80

90

100

Spec Diets Dx Ger Surg Education

% RespNursing Scrnn=442

% RespNutritionScrn n=252

Criteria Used By Nursing/Nutrition to Identify Patients at Nutrition Risk (Inpatient)

16

30

17

46

23

34

1017 19

74

12

61

0

10

20

30

40

50

60

70

80

90

100

Age wt/ht FoodAllergy

ConcFormula

NPO/Clr VisceralPro

% RespNursingScrnn=442

% RespNutrScrnn=252

How Many Levels of Risk Does Your Screening System Include?

4341

16

0

5

10

15

20

25

30

35

40

45

Two Three Four or More

% of Respondentsn=522

Has Your Inpt Screening System Been Validated for Sensitivity/Specificity?

26

74

26

74

0

10

20

30

40

50

60

70

80

Sensitivity Specificity

Yes

No

% of respondents

How Well Do Inpt Screening Criteria Effectively Identify Nutrition Risk?

71

34

15

54

1

813

4

0

10

20

30

40

50

60

70

80

All/Most of theTime

Sometimes Half to Never n/a

Nutrition StaffcriteriaNursing StaffCriteria

Validation of Nutrition Screening Tools in Acute Care

Criteria Population Comment

Kovacevichet al, NCP1997

Dx, intake,IBW, Wt hx

Adult acutecare ptsn=186

Sensitivity 84.6%;specificity 62.6 byPAB. (Nearly fullpage screen form)

FergusonM.Nutrition 1Jun 1999

Appetite,unintentionalwt loss

Adult acutecare ptsn=408(Australia)

High inter-raterreliability (93-97%)High sensitivity/specificity vs SGA

Laporte M,JNHA 1 Jan2001

BMI + wtlossBMI +albumin

Elderlyacute /LTCn=142(Canada)

Validity 60.5%-93.1% vs RDnutrition assessment

Validation of Nutrition Screening Tools in Acute Care Criteria Population Comment

Mezoff A. Pediatrics 1 Apr 1996

Lngth/ht, wt/ht %ile, wt hx, dx, lab data

PICU pts w/ RSV

High nutr risk score associated with poor outcome; (nearly full page form)

Burden ST. J Hum Nutr Diet 2001

BMI, MUAC, wt hx, intake vs needs

100 med/surg/ elderly hospital pts (UK)

Sensitivity 78%; specificity 52% vs nutrition assessment (overestimates pts at moderate risk)

Adult-Geriatric Inpatient Screening Criteria at MHS 1. Pregnant or Lactating mother admitted to unit

other than antepartum or mother-baby  2. Significant unintentional weight loss >=10 lb. in

past 1-2 months   3 Patient DESIRES EDUCATION on a

therapeutic diet  4. Patient unable to take oral or other feedings

>=5 days prior to admission 5. Patient on enteral or parenteral feedings  6. Geriatric patient (80 years plus) admitted for

surgical procedure  7. Patient with skin breakdown (decubitus ulcer) 

Infant-Child-Adolescent Inpatient Screening Criteria at MHS 1. Recent weight loss 2. On special diet and NEEDS EDUCATION 3. Has feeding tube or on parenteral feedings 4. Diabetic 5. Receives high calorie feeds/concentrated

formula 6. Food allergy 7. Failure to thrive 8. Feeding problems/intolerance 9. Teen who is pregnant or lactating 10. Child being breast fed

MHS Adult Ambulatory Screen

MHS Peds Ambulatory Screen

MetroHealth Screening Prompt Criteria in Peds Ambulatory ClinicsChildren <2 Years <10 %ile weight/length >90 %ile weight/length

Children 2-18 Years < 10 %ile BMI/age >85 %ile BMI/age

Nursing Admission Screens: Most Common Criteria MHMC (Feb 17-Mar 2, 2003)

8

39

13

2523

86 5

0

5

10

15

20

25

30

35

40

EN/PN Wt Loss Intake Education Skin Preg/Lact Age ConcFeeds

# of Pts, n=101

% of Positive Nutrition Screens Classified as High Risk after Review (by Criterion)

100

70

82

53

61

17

00

10

20

30

40

50

60

70

80

90

100

EN Skin Intake Wt Education Age Preg/Lact

% ofPositiveScreens

Nutrition Screening at MetroHealth

Consistent with national practice in terms of criteria, procedures, and time frames

With the exception of TJC-mandated criteria, specificity ranges from 50-100%

TJC-mandated criteria are poor predictors of nutrition risk

No data on sensitivity (e.g. what percentage of at risk pts are we discovering?)

Issues in Nutrition Screening

Most nutrition screening in acute and ambulatory settings is done by staff other than nutrition professionals

Based on a national survey, identified at-risk patients are referred to nutrition professionals less than half the time

Issues in Nutrition Screening Much of the research that exists validates

more comprehensive nutrition screening tools, e.g. MNA in the elderly

Little research has been done to validate or evaluate nutrition screening as it currently exists in most acute care institutions: a process using limited data obtained on admission by nursing staff.

There is no “gold standard” of nutrition status that can be used as a benchmark

ADA Screening Evidence Analysis Work Group Convened fall, 2007 Will develop definitions and formulate

questions for evidence analysis regarding nutrition screening

Members of Screening EAL Work Group Chair: Pam Charney, PhD, RD, CNSD, consultant Vicki Castellanos, PhD, RD, Florida International

University, educator Cinda Chima, MS, RD, University of Akron,

educator Maree Ferguson, MBA, PhD, RD, Queensland,

Australia, clinical manager Nancy Nevin-Folino, MEd, RD, CSP, LD, FADA,

Children’s Hospital, Dayton, Oh, practitioner Judy Porcari, MBA, MS, RD, Clinical Manager Annalynn Skipper, PhD, RD, FADA, Consultant